Treatment recommendations for hsts transkids
by S. Alejandra Velasquez
Our first recommendation is for the medical differentiation of
homosexual transsexuality and autogynephilic transsexuality as two
completely unrelated conditions. The two conditions should not be
lumped together as different forms of the same phenomenon but should have
separate diagnostic sections in the DSM IV.
One of the biggest problems facing transkids is the lack of meaningful
counseling as children and treatment protocols as teenagers
specifically helpful for our population. This is in part because we
have no meaningful social category within which we may be
therapeutically understood. Our criticism of the current gender
identity model of transsexuality is not a theoretical objection,
it is because this model is taylored exclusively to the social and therapeutic
needs of AGP transsexuals and is irrelevant to homosexual
transsexuals. Our problem is not with autogynephilia but to the social
impact of an autogynephilia centered psychological model upon our
lives. Meaningful medical help for our type of transsexual can only be
provided with an adequate understanding of the etiologies, problems
and desired goals specific to hsts.
In almost all ways, hsts and agp transexuality are completely
different conditions which happen to intersect with the one shared
experience of genital surgery. Our lives both before and after that
shared experience are extremely divergent. It is only logical that the
two different psychological conditions which have no shared
symptomology, would have very different diagnoses and modalities of
treatment which reflect those differences.
We also recommend counseling be
available for children who are possible transkids, especially as they
approach puberty. We are not advising that children be treated for
childhood gender identity disorder, a diagnosis we dispute. We are
recommending counseling when it seems appropriate for the difficulty
of being different and misunderstood as children.
Counselors or therapists need to be
knowlegable about homosexual transsexuality, though we realize that
cannot happen overnight. It should not be assumed that someone who
is proficient and knowlegable in evaluating and treating agp
transsexuals is also qualified to counsel or treat hsts transkids.
Feminine boys are stigmatized in almost all societies, but trying to
prevent stigmatization by traumatizing potentially gay and hsts
children into more acceptable sex typed behavior for their birth sex
only creates more shame in adults. It is hard being a transkid but we
know that with understanding and sensible treatment choices, the
outcome can be very good. It should be understood that publicly
out adult agp transsexuals are not representative of adult hsts. It's
better to be a well adjusted adult with a different childhood than an
unhappy adult with a more normal appearing childhood. Gender variant
children should have meaningful psychotherapeutic support for coping
with social stigmatization and for making logical decisions about
their lives and bodies as they approach puberty.
A new set of relevant guidlines for counseling and treatment of hsts
teenagers should be developed which will provide access to helpfull
and appropriate medical procedures.
The Harry Benjamin (Now WPATH - editor) Standards of Care are inappropriate and unhelpful
for hsts in most ways. There have been improvements to the HBSoC
which potentially benefit hsts adolesecents but because the current
understanding of transsexuality excludes homosexual transkids those
changes are really focussed on a therapeutic model specific to agp
teenagers.
It seems paradoxical but in many ways being a feminine transkid in
western society can make the process of getting access to medical help
more difficult, not easier. Parents do not want to accept that they
have a child who is very different and the single most important
factor in a transkids life is parental support and
understanding.
Adolescence is the time when transkids unequivably differentiate from
non-transsexual children because it is increasingly impractical for us
to live socially as boys as we get older and because there is no
natural and practical developmental pathway for our sexuality as
feminine boys who are sexually attracted to males. Our medical options
should enable our ability to mature socially and sexually as
teenagers. All of the following recommendations are based on the
ability of transkids to determine what will benefit them personally,
socially and sexually as they mature. We do not advocate at all the
imposition of unwanted medicalization, only the logical
self-actualized access to helpful medical technology which we know to
be important and helpful to our population.
Some Specific Recommendations
Medical intervention to avoid masculinizing puberty.
This is the most important medical factor in our lives and will
determine what choices we have and our chances for happiness later in
life. Though transkids tend to be unusually feminine in appearance,
masculinizing puberty can adversly affect our ability to present
normally. Most hsts kids express their dissatisfaction with their sex
identity to parents as young children and certainly around puberty,
commonly between age 12 and 16 but also both younger and older. Unlike
AGP transsexuals, it is usually no surprise to the families of hsts
because our behavior and socialization has been obviously different
from a young age. Transkids are very motivationally homogenous and
uncomplex in their transsexuality, so it's logical that the decision
to initiate hormonal intervention comes with an hsts pre-teens or
teenagers request for help. Ideally we recommend a combination of
estrogen to initiate feminizing puberty and anti-androgens to prevent
any masculinization prior to surgery.
Change of social role, transition, during adolescence.
Because hsts transkids fit in socially and behaviorally better as
girls our social lives as teenagers will simply benefit from living as
the most appropriate sex to reduce social stigma and all the resulting
frustration and psychological difficulty it causes us. In our
experience transkids who have had medical and parental help in avoiding
male puberty and living in their logical sex role early seem to do far
better and have less problems than other hsts teenagers.
If it is not possible to begin feminizing puberty at the appropriate
age then puberty delaying anti-androgens are the next best
alternative. Preventing masculinizing puberty is of primary
importance.
The fixed age requirements for
begining hormonal intervention and surgery should be eliminated in
favor of providing rational help to hsts transkids as it is
requested. The requirement of the RLE (real life experience) should be
eliminated for hsts transkids in favor of humanistic and common sense
help.
Some of us might benefit best by transitioning at age 10 or 12, some
at 16 or 18, depending on our social and familial situations. We do
not view transition as a "test" or "real life experiences" but rather
as positive changes in our lives. By the time we are young teenagers
it is very obvious that the "real life experience" of living as boys
has not been workable for us. There is no reason to require transkids
to wait until they are 16 to begin hormone therapy or transition or to
wait until they are 18 for permission to have SRS. For those of us
denied services we often simply acquire hormones illegally and
"transition" socially with no parental or professional support.
Surgery should be available after the adjustment is made to hormones
and transition, when we feel ready for that step. It is extremely
difficult to live for years prior to surgery for hsts transkids who do
cannot pass as boys and who have transitioned. Ideally there should be
a minimum of time spent "in-between" sexes because it is very
psychologically damaging and potentially dangerous. Once an hsts
transkid has transitioned and is doing well on hormones and states she
is happy and ready to go forward then surgery should be
available.
It's cruel to ask an adolescent at their sexual prime to be assexual
for a year or two years. The so called "real life test" may be useful
for autogynephilic transsexuals to see if they can make the huge
adjustment to living in a nominally female role and if they can
sustain the criticism from their family, co-workers, and take the
harrasement from insensitive people. Hsts transkids on the other hand
are not making a very large adjustment, receive less harrasement and
criticism in a female role then in their prior nominally male role.
While there is a fear that autogynephilic transsexuals, who most often
have used their genitals for sexual relations as males, maybe have
'post-op regret' at the loss of that function, hsts transkids do not.
It is frustrating for transkids to live as female, likely getting lots
of attention from men for the first time in their lives, but not being
able to date (these are adolescents). While the Harry Benjamin
Standards of Care recommend a one year RLE for adult transsexuals,
transkids who transition as teens in order to be happier and
emotionally adjusted often find themselves in the situation of having
to wait 2 or 4 or more years for surgery. This is unfair, harmful and
dangerous.
Counseling for teenage transkids
and their parents should be with specific understanding of the needs
of hsts transkids which are generally different from the needs of AGP
transsexuals and most definitely from those of older AGP
transsexuals.
It is a paradox of the current understanding of transsexuality that
hsts transkids who have spent their childhoods coping with the
difficulty of being unacceptably feminine should be misunderstood and
marginalized in obtaining medical help as m2f transsexuals but that is
the situation most of us find ourselves in as teenagers. Typically
"gender therapists" are familiar with the standard transsexual
narrative which explains that transsexuals have a powerful urge to
change their sex no matter what the cost in order to be congruent with
some internal sense of their "gender identity", which may or may not
have any relationship to their social identity. It does not occur to
hsts transkids to explain themselves this way because that
understanding is specific to agp transsexuals; transkids are motivated
by the need to change their sex to match their external and socially
connected genders and to have a chance to express their natural
sexuality without risking being emotionally or physically harmed. We
often find the less someone knows about 'transsexuals' the more able
they are to help us, because what we really need is only a common
sense understanding and not a whole philosophy on what
'transsexuality' ought to be about. Practical counseling for transkid
teenagers should be focussed on providing meaningful help and
not on theoretical abstractions about internal gender identity.
For example:
Our sexuality is important to us. Simply, social and sexual
frustration is a major problem for transkids. This should not be a
startling insight at all since adolescence is when we all learn about
our sexuality - hsts transkids are no different. It is a common myth
of the transsexual narrative that transsexuality does not involve
sexuality but this is not true of hsts. Do not be surprised if hsts
transkids are very interested in sex and sexuality.
Transkids like boys. They would like boys even if they stayed male.
Being physically attractive is important to transkids because they
want to attract boys, not to 'confirm their female identity', but
simply because they like boys. Having good relationships is important
in living a decent life, and the fact that this is significant to them
does not mean that they're conflicted about their gender issues, it
just means that they have the same concerns that normal people do.
Teen hsts should not be required to attend support groups for older
transsexuals. The two groups have nothing in common and many of us
have had upsetting experiences being forced to attend meetings with
people who have had a transvestic etiology as opposed to a homosexual
one.
Hsts transkids should not be subjected to embarrassing medical
attention or incredulity over our birth sex when we talk to healthcare
professionals. It is common for us to be asked to drop our pants by
psychiatric personel for instance or to be told we may be intersexed
rather than hsts. Endocrinologists frequently take it upon themselves
to practice unasked for psychiatry with us. These attitudes are
harmful and upsetting to teenagers who very often already have more
than enough problems with embarrassment at home and school. We deserve
to be treated with respect just like other teenagers.
When an hsts transkid goes on hormones, don't expect them to feel
'more complete' or 'more at peace' with themselves as a diagnostic feature of
being a transsexual. Dressing up at home or doing little things to
affect a more 'feminine' appearance while presenting as a gay boy,
offers no relief to transkids because their gender issues are social
and not personal. Suggesting they do so will only confuse them.
Transkids who have not transitioned socially are unlikely to put a
great deal of importance on what pronoun you use for them or what name
they're called. This is not a sign of having ambivalence to their
gender or feeling conflicted about which gender they want to be; given
that their gender is already at issue they may simply not care how a
health care provider addresses them. Showing 'sensitivity' by trying
to respect their 'gender identity', or worse insisting that they
declare their 'gender identity', will only make them feel
embarrassed. Hsts transkids are practical about identity issues so
don't make a bigger deal about it than they do.
Transkids do not have feminine alter egos, they don't have 'guy mode'
or 'girl mode', nor do they dress 'en femme.' Typically their voice
is natural and untrained not a deliberate 'girl voice.' Assuming the
way a transkid presents is just one of several "modes" they have is
very likely incorrect; since they never develop a gender normative
male presentation there is no dichotomy between 'guy mode' and 'girl
mode' for them. Transkids only have one personality regardless of how
they're dressed or what name they introduce themselves by.
Cosmetic surgery for transkids should be regarded the same was as
cosmetic surgery in straight women. If they want cosmetic surgery,
they want it to make them more attractive, so that they feel more
confident in their apperance and so they're more desirable to men.
Its not a surgery to 'confirm' their gender.
Transkids are likely to regard SRS in terms of funcitonality: they
will want the surgery so they can have normal sex with straight men.
There is nothing wrong with wanting it for inherently sexual reasons,
and it should not surprise anyone that surgery on genitals is for
sexual reasons. This should not be seen as a reason not to endorse
their operation or operate on them. No one should have to suffer from
a sexual dysfunction.
A Better Paradigm for Understanding and Better Treatment
Hsts transkids are caught between two harmfull and irrelevant social
constructs: as children our gender variance, childhood gender identity
disorder, is socially and parentally unacceptable. We are often
problem children because we are unable to modify our behavior and
achieve a believable gender presentation as boys. The current model of
transsexuality is focussed on benefitting autogynephilic transsexuals,
"men" who wish to "become women" and does not address the needs of
transkids who need to get through adolescence with good medical help
for maturing into the appropriate sex with minimum harm. A better way
to think about hsts transkids is to understand how different children
can grow up and mature into a more appropriate and workable sex,
gender and sexuality, not "transitioning" into the "opposite sex"
since our gender as boys is never adequately socially realized. We
are one of the groups of children whose sex and gender differentiation
isn't complete until the social part of our development plays out
sufficiently into adolescence, when we are able to make the best
logical choices for ourselves about our own lives.
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